Every finding on record at Comforter Hospice Inc

Upon patient record review, 2 of 14 (Patient 1 and 6) did not have evidence that the patient received information about the services covered under the hospice benefit.

Upon patient record review 1 of 14 (Patient 9) did not have evidence that the hospice Registered Nurse completed an initial assessment within 48 hours after the election of hospice care in accordance with §418.24. Patient 9 election date on consent forms is 4/4/24 and Registered Nurse completed initial assessment on 4/8/24. There was no evidence of additional documentation noting reason for initial assessment being completed after 48 hrs after the election of hospice.

Upon patient record review, 4 of 14 (Patient 3, 4, 5 and 8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 3 medication profile includes "Voltaren 1% top gel to affected areas daily as needed" with no location identified and also on "Diclofenac sodium 3 % topical gel four times a day as needed for joint pain"; duplicative therapy, "Aspirin 81 mg tab 1 tab po once daily for blood thinner" and "Aspirin 81 mg chewable tablet 1 tab by mouth daily" for clot prevention; duplicative therapy. "Miralax powder 17 gm packet oral as needed for constipation" with no frequency and no diluent instructions. O2 concentrator is on the plan of care under DME but no dose and frequency under medication profile. Patient 4 medication profile includes "Diclofenac sodium 3% topical gel twice daily" with no specified location identified. Patient 5 medication profile includes "Erythromycin 0.5% Ophthalmic Ointment apply half inch to the eye three times a day for infection" with no indication of right eye, left eye or both eyes, "Albuterol 90mcg/actuation Inhalation Aerosol 1 puff respiratory (inhalation) as needed for wheezing" with no frequency, "Bacitracin First Aid Antibiotic Topical Ointment 500 units 1 app topical twice a day" with no location identified, "Triamcinolone Acetonide 0.05% Topical Ointment 0.05 % 1 application twice a day" with no location identified. Patient 8 medication profile includes "Clonidine 0.1 mg tab 1 tab po every 6 hrs prn htn" with no blood pressure parameters, "Dulcolax 10 mg rectal supp 1 supp rectal as needed for constipation" with no frequency, "Fleet disposable rectal enema 7g unit, 1 unit rectally as needed" with no frequency, "Milk of magnesia 1200mg/15ml, 30 ml po as needed for constipation" with no frequency.

Upon patient record review, 4 of 14 (Patient 3, 4, 5 and 8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3 plan of care includes "Voltaren 1% top gel to affected areas daily as needed" with no location identified and also on "Diclofenac sodium 3 % topical gel four times a day as needed for joint pain"; duplicative therapy, "Aspirin 81 mg tab 1 tab po once daily for blood thinner" and "Aspirin 81 mg chewable tablet 1 tab by mouth daily" for clot prevention; duplicative therapy. "Miralax powder 17 gm packet oral as needed for constipation" with no frequency and no diluent instructions. O2 concentrator is on the plan of care under DME but no dose and frequency under medication profile listed on the POC. Patient 4 plan of care includes "Diclofenac sodium 3% topical gel twice daily" with no specified location identified. Patient 5 plan of care includes "Erythromycin 0.5% Ophthalmic Ointment apply half inch to the eye three times a day for infection" with no indication of right eye, left eye or both eyes, "Albuterol 90mcg/actuation Inhalation Aerosol 1 puff respiratory (inhalation) as needed for wheezing" with no frequency, "Bacitracin First Aid Antibiotic Topical Ointment 500 units 1 app topical twice a day" with no location identified, "Triamcinolone Acetonide 0.05% Topical Ointment 0.05 % 1 application twice a day" with no location identified. Patient 8 plan of care includes "Clonidine 0.1 mg tab 1 tab po every 6 hrs prn htn" with no blood pressure parameters, "Dulcolax 10 mg rectal supp 1 supp rectal as needed for constipation" with no frequency, "Fleet disposable rectal enema 7g unit, 1 unit rectally as needed" with no frequency, "Milk of magnesia 1200mg/15ml, 30 ml po as needed for constipation" with no frequency.

Upon patient record review 1 of 14 (Patient 1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1 POC and Aide Assignment has aide 2 x w. The week of 2/23-3/1 only 1 visit made, week of 3/2-3/8 and 3/9-3/15 no visits made. There were no evidence of missed visit forms completed.

Upon patient record review 1 of 1 applicable (Patient #5) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #5 The HHA visit frequency ordered 2x week. The week of 8/8/21 there was only evidence of 1 HHA visit made.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that each patient record contains a signed election statement in accordance with 418.24 Patient #2 The hospice election form did not include notification of the individual's (or representative's) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice or information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information.

Upon patient client record review, 2 of 5 (Patient #1 and #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1 Hospice Certification form indicated the dates for initial benefit period as 11-1-21 to 1-20-22. The correct 90 day period from start of care is: 11-1-21 to 1-29-22 Patient #2 Hospice Certification form indicated the dates for initial benefit period as 9-25-21 to 12-22-21. The correct 90 day period from start of care is: 9-25-21 to 12-23-21